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medications
Local Anesthetic Volumes by Procedure
ProcedureAnestheticConcentrationVolumeKey Notes
Lumbar TFESILidocaine or Bupivacaine1% / 0.25%1-2 mL totalTotal injectate 1.5-2.5 mL including steroid. Less volume = more targeted.
Cervical TFESILidocaine (NOT ropivacaine)1%0.5-1 mL totalRopivacaine precipitates with dexamethasone. Smaller volumes for cervical.
Interlaminar ESILidocaine or Bupivacaine1% / 0.25%3-6 mL totalLarger volumes for broader coverage. Caution: excessive LA can cause motor block.
Caudal ESILidocaine or Bupivacaine1% / 0.25%10-20 mL totalLarger volumes needed to fill sacral epidural space. Monitor for motor block.
Diagnostic MBB (Lumbar)Lidocaine or Bupivacaine2% / 0.5%0.25-0.5 mL per targetSmall volume is CRITICAL for diagnostic specificity. Excess volume spreads to adjacent structures.
Diagnostic MBB (Cervical)Lidocaine or Bupivacaine2% / 0.5%0.2-0.25 mL per targetEven smaller volumes for cervical. TON target gets 0.2 mL.
SI Joint InjectionLidocaine or Bupivacaine1% / 0.25%1-2 mL (joint capacity ~1 mL)Joint capacity is small. Excess volume causes capsular rupture and extra-articular spread.
C1-2 Joint InjectionLidocaine or Bupivacaine1% / 0.25%0.5-1 mL (joint < 1 mL)Tiny joint. Use 0.1-0.2 mL contrast for arthrogram before anesthetic.
Selective Nerve Root BlockLidocaine2%0.5 mLLidocaine preferred (shorter action for diagnostic clarity). Volume must be small for selectivity.
Stellate Ganglion BlockLidocaine or Bupivacaine1% / 0.25%5-10 mLConfirm with Horner syndrome (miosis, ptosis). Add steroid for therapeutic.

Notes

  • 1. For diagnostic blocks: sedation is discouraged as it increases false-positive rate
  • 2. Lidocaine onset: 2-5 min, duration: 1-2 hours. Bupivacaine onset: 5-15 min, duration: 4-8 hours.
  • 3. For dual diagnostic MBBs: use different-duration agents on separate visits to confirm concordant response
  • 4. Total maximum dose: Lidocaine 4.5 mg/kg (7 mg/kg with epi), Bupivacaine 2.5 mg/kg

Source: IPSIS Technical Manual, SIS Practice Guidelines | Updated: 2026-04-03